Chapter 12: Shock, Sepsis, and Multiple Organ Dysfunction Syndrome

Sole: Introduction to Critical Care Nursing, 7th Edition

Multiple Choice

1. The nurse is caring for a patient admitted with hypovolemic shock. The nurse palpates thready brachial pulses but is unable to auscultate a blood pressure. What is the best nursing action?

a. Assess the blood pressure by Doppler.

b. Estimate the systolic pressure as 60 mm Hg.

c. Obtain an electronic blood pressure monitor.

d. Record the blood pressure as “not assessable.”

ANS: A

Auscultated blood pressures in shock may be significantly inaccurate due to vasoconstriction. If blood pressure is not audible, the approximate value can be assessed by palpation or ultrasound. If brachial pulses are palpable, the approximate measure of systolic blood pressure is 80 mm Hg. This action has the potential to delay further assessment of a compromised patient in shock. Documenting a blood pressure as not assessable is inappropriate without further attempts using different modalities.

DIF: Cognitive Level: Apply/Application REF: p. 260

OBJ: Develop an individualized plan of care that includes nursing diagnosis, expected outcomes, nursing interventions, and rationales. TOP: Nursing Process Step: Assessment

MSC: NCLEX Client Needs Category: Physiological Integrity a. Creatinine 1.0 mg/dL b. Lactate 6 mmol/L c. Potassium3.8 mEq/L d. Sodium140 mEq/L

2. The nurse has just completed an infusion of a 1000 mL bolus of 0.9% normal saline in a patient with severe sepsis. One hour later, which laboratory result requires immediate nursing action?

ANS: B

Lactate level has been used as an indicator of decreased oxygen delivery to the cells, adequacy of resuscitation in shock, and as an outcome predictor. All other listed values are within normal limits and do not require additional follow-up.

DIF: Cognitive Level: Remember/Knowledge REF: p. 263 Laboratory Alert box

OBJ: Relate assessment findings to the classification and stage of shock.

TOP: Nursing Process Step: Assessment

MSC: NCLEX Client Needs Category: Physiological Integrity a. Breath sounds and capillary refill b. Blood pressure and oral temperature c. Oral temperature and capillary refill d. Right atrial pressure and urine output

3. The nurse has been administering 0.9% normal saline intravenous fluids in a patient with severe sepsis. To evaluate the effectiveness of fluid therapy, which physiological parameters would be most important for the nurse to assess?

ANS: D

Early goal-directed therapy includes administration of IV fluids to keep central venous pressure at 8 mm Hg or greater. Combined with urine output, fluid therapy effectiveness can be adequately assessed. Evaluation of breath sounds assists with determining fluid overload in a patient but does not evaluate the effectiveness of fluid therapy. Capillary refill provides a quick assessment of the patient’s overall cardiovascular status, but this assessment is not reliable in a patient who is hypothermic or has peripheral circulatory problems. Evaluation of oral temperature does not assess the effectiveness of fluid therapy in patients in shock.

DIF: Cognitive Level: Evaluate/Evaluation

OBJ: Describe management strategies for each type of shock.

TOP: Nursing Process Step: Assessment

MSC: NCLEX Client Needs Category: Physiological Integrity

REF: pp. 283-284 a. The assessed values are within normal limits. b. The patient is at risk for developing cardiogenic shock. c. The patient is at risk for developing fluid volume overload. d. The patient is at risk for developing hypovolemic shock.

4. A patient is admitted to the critical care unit following coronary artery bypass surgery. Two hours postoperatively, the nurse assesses the following information: pulse is 120 beats/min; blood pressure is 70/50 mm Hg; pulmonary artery diastolic pressure is 2 mm Hg; cardiac output is 4 L/min; urine output is 250 mL/hr; chest drainage is 200 mL/hr. What is the best interpretation by the nurse?

ANS: D

Vital signs and hemodynamic values assessed collectively include classic signs and symptoms of hypovolemia. Both urine output and chest drainage values are high, contributing to the hypovolemia. Assessed values are not within normal limits.

NURSINGTB.COM

A cardiac output of 4 L/min is not indicative of cardiogenic shock. The patient is at risk for hypovolemia, not volume overload, as evidenced by excessive hourly chest drainage and urine output.

DIF: Cognitive Level: Analyze/Analysis

REF: pp. 271-272 | Table 12-5

OBJ: Relate assessment findings to the classification and stage of shock.

TOP: Nursing Process Step: Assessment

MSC: NCLEX Client Needs Category: Physiological Integrity a. Human albumin infusion b. Hypotonic saline solution c. Lactated Ringer’s bolus d. Packed red blood cells

5. A patient is admitted after collapsing at the end of a summer marathon. The patient is lethargic, with a heart rate of 110 beats/min, respiratory rate of 30 breaths/min, and a blood pressure of 78/46 mm Hg. The nurse anticipates administering which therapeutic intervention?

ANS: C

The patient is experiencing symptoms of hypovolemic shock. Isotonic crystalloids, such as normal saline and lactated Ringer’s solutions, are the priority intervention. Albumin and plasma protein fraction (Plasmanate) are naturally occurring colloid solutions that are infused when the volume loss is caused by a loss of plasma rather than blood, such as in burns, peritonitis, and bowel obstruction. Hypotonic solutions rapidly leave the intravascular space, causing interstitial and intracellular edema and are not used for fluid resuscitation. There is no evidence to support a transfusion in the given scenario.

DIF: Cognitive Level: Analyze/Analysis

OBJ: Describe management strategies for each type of shock.

TOP: Nursing Process Step: Intervention

MSC: NCLEX Client Needs Category: Physiological Integrity

REF: p. 265 a. High pulmonary artery occlusive pressure and high cardiac output b. High systemic vascular resistance and low cardiac output c. Low pulmonary artery occlusive pressure and low cardiac output d. Low systemic vascular resistance and high cardiac output

6. The nurse is caring for a patient in the early stages of septic shock. The patient is slightly confused and flushed, with bounding peripheral pulses. Which hemodynamic values is the nurse most likely to assess?

ANS: D

As a consequence of the massive vasodilation associated with septic shock, in the early stages, cardiac output is high with low systemic vascular resistance. In septic shock, pulmonary artery occlusion pressure is not elevated. In the early stages of septic shock, systemic vascular resistance is low and cardiac output is high. In the early stages of septic shock, cardiac output is high.

NURSINGTB.COM

DIF: Cognitive Level: Remember/Knowledge

REF: Table 12-5

OBJ: Relate assessment findings to the classification and stage of shock.

TOP: Nursing Process Step: Assessment

MSC: NCLEX Client Needs Category: Physiological Integrity a. Acetaminophen suppository b. Blood cultures from two sites c. IV antibiotic administration d. Isotonic fluid challenge

7. The nurse is caring for a patient admitted with severe sepsis. Vital signs assessed by the nurse include blood pressure 80/50 mm Hg, heart rate 120 beats/min, respirations 28 breaths/min, oral temperature of 102° F, and a right atrial pressure (RAP) of 1 mm Hg. Which intervention should the nurse carry out first?

ANS: D

Early goal-directed therapy in severe sepsis includes administration of IV fluids to keep RAP/CVP at 8 mm Hg or greater (but not greater than 15 mm Hg) and heart rate less than 110 beats/min. Fluid resuscitation to restore perfusion is the immediate priority. Broad-spectrum antibiotics are recommended within the first hour; however, volume resuscitation is the priority in this scenario.

DIF: Cognitive Level: Analyze/Analysis

OBJ: Describe management strategies for each type of shock.

REF: pp. 283-284

TOP: Nursing Process Step: Intervention

MSC: NCLEX Client Needs Category: Physiological Integrity a. A patient admitted with abdominal pain and an elevated white blood cell count b. A patient with a temperature of 102° F and a general dermal rash c. A patient with a 2-day history of nausea, vomiting, and diarrhea d. A patient with slight rectal bleeding from inflamed hemorrhoids

8. Which patient being cared for in the emergency department is most at risk for developing hypovolemic shock?

ANS: C

Excessive external loss of fluid may occur through the gastrointestinal tract via vomiting and diarrhea, which may lead to hypovolemia. There is no evidence to support significant fluid loss in the remaining patient scenarios.

DIF: Cognitive Level: Remember/Knowledge REF: p. 271

OBJ: Relate assessment findings to the classification and stage of shock.

TOP: Nursing Process Step: Assessment

MSC: NCLEX Client Needs Category: Physiological Integrity a. Dobutamine b. Furosemide c. Phenylephrine d. Sodium nitroprusside

9. The nurse is caring for a patient admitted with cardiogenic shock. Hemodynamic readings obtained with a pulmonary artery catheter include a pulmonary artery occlusion pressure (PAOP) of 18 mm Hg and a cardiac index (CI) of 1.0 L/min/m2. What is the priority pharmacological intervention?

ANS: A

A high PAOP and a low cardiac index are findings consistent with cardiogenic shock. Positive inotropic agents (e.g., dobutamine) are given to increase the contractile force of the heart. As contractility increases, cardiac output and index increase and improve tissue perfusion. Administration of furosemide will assist only in managing fluid volume overload. Phenylephrine administration enhances vasoconstriction, which may increase afterload and further reduce cardiac output. Sodium nitroprusside is given to reduce afterload. There is no evidence to support a need for afterload reduction in this scenario.

DIF: Cognitive Level: Analyze/Analysis

REF: p. 275 | Table 12-4 | Table 12-5

OBJ: Describe management strategies for each type of shock.

TOP: Nursing Process Step: Intervention

MSC: NCLEX Client Needs Category: Physiological Integrity a. Diphenhydramine 50 mg intravenously b. Epinephrine 3 to 5 mL of a 1:10,000 solution intravenously c. Methylprednisolone 125 mg intravenously d. Ranitidine 50 mg intravenously

10. Ten minutes following administration of an antibiotic, the nurse assesses a patient to have edematous lips, hoarseness, and expiratory stridor. Vital signs assessed by the nurse include blood pressure 70/40 mm Hg, heart rate 130 beats/min, and respirations 36 breaths/min. What is the priority intervention?

ANS: B

The patient is exhibiting signs of anaphylaxis. For anaphylaxis with hypotension, epinephrine 0.3 to 0.5 mg (3 to 5 mL of 1:10,000 solution) is administered intravenously. Diphenhydramine will help block histamine release, but epinephrine is the drug of choice for anaphylaxis with hypotension. Corticosteroids, such as methylprednisolone, are used to reduce inflammation, but epinephrine is the drug of choice for anaphylaxis with hypotension. Ranitidine will help block histamine release, but epinephrine is the drug of choice for anaphylaxis with hypotension.

DIF: Cognitive Level: Analyze/Analysis

OBJ: Describe management strategies for each type of shock.

TOP: Nursing Process Step: Intervention

MSC: NCLEX Client Needs Category: Physiological Integrity

REF: pp. 79-280 a. High pulmonary artery diastolic pressure and low cardiac output b. Low pulmonary artery occlusive pressure and low cardiac output c. Low systemic vascular resistance and high cardiac output d. Normal cardiac output and low systemic vascular resistance

11. A patient is admitted to the cardiac care unit with an acute anterior myocardial infarction. The nurse assesses the patient to be diaphoretic and tachypneic, with bilateral crackles throughout both lung fields. Following insertion of a pulmonary artery catheter by the physician, which hemodynamic values is the nurse most likely to assess?

ANS: A

In cardiogenic shock, cardiac output and cardiac index decrease. Right atrial pressure, pulmonary artery pressures, and pulmonary artery occlusion pressure increase and volume backs up into the pulmonary circulation and the right side of the heart. Pulmonary artery occlusion pressure increases in cardiogenic shock. Systemic vascular resistance is high and cardiac output is low in cardiogenic shock. Cardiac output is low and systemic vascular resistance is high in cardiogenic shock.

DIF: Cognitive Level: Analyze/Analysis

REF: p. 275 | Table 12-4 | Table 12-5

OBJ: Relate assessment findings to the classification and stage of shock.

TOP: Nursing Process Step: Assessment

MSC: NCLEX Client Needs Category: Physiological Integrity a. Arterial vasodilation b. High urine output c. Increased parasympathetic stimulation d. Increased sympathetic stimulation

12. During the initial stages of shock, what are the physiological effects of decreased cardiac output?

ANS: D

A reduction in blood pressure leads to an increase in catecholamine release, resulting in an increase in heart rate and contractility to improve cardiac output. Decreased cardiac output leads to arterial vasoconstriction in an effort to increase blood pressure. Low urine output results, as decreased cardiac output reduces blood flow to the kidneys. There is an increase in sympathetic stimulation in response to a decrease in cardiac output.

DIF: Cognitive Level: Remember/Knowledge REF: p. 260

OBJ: Correlate the four classifications of shock to their pathophysiology.

TOP: Nursing Process Step: Assessment

MSC: NCLEX Client Needs Category: Physiological Integrity a. Central nervous system b. Gastrointestinal system c. Renal system d. Respiratory system

13. While monitoring a patient for signs of shock, the nurse understands which system assessment to be of priority?

ANS: A

The central nervous system experiences decreased perfusion first. The patient will have central nervous system changes early during the course of shock, such as changes in the level of consciousness. Although the gastrointestinal, renal, and respiratory systems also experience changes during shock, changes in the central nervous system provide the earliest indication of decreased perfusion.

DIF: Cognitive Level: Remember/Knowledge REF: p. 260

OBJ: Relate assessment findings to the classification and stage of shock.

TOP: Nursing Process Step: Assessment

MSC: NCLEX Client Needs Category: Physiological Integrity a. “The action of the machine will improve blood supply to the damaged heart.” b. “The machine will beat for the damaged heart with every beat until it heals.” c. “The machine will help cleanse the blood of impurities that might damage the heart.” d. “The machine will remain in place until the patient is ready for a heart transplant.”

14. The nurse is caring for a patient in cardiogenic shock being treated with an intraaortic balloon pump (IABP). The family inquires about the primary reason for the device. What is the best statement by the nurse to explain the IABP?

ANS: A

The IABP improves coronary artery perfusion, reduces afterload, and improves perfusion to vital organs. An IABP acts through counterpulsation, augmenting the pumping action of the heart, displacing blood to improve both forward and backward blood flow. It does not “beat” for the damaged heart. An IABP does not filter blood impurities. An IABP is designed as a temporary therapy for use when pharmacological interventions alone are not effective. It is indicated for short-term use, not as a bridge to transplant.

DIF: Cognitive Level: Understand/Comprehension REF: p. 276

OBJ: Describe management strategies for each type of shock.

TOP: Nursing Process Step: Intervention

MSC: NCLEX Client Needs Category: Physiological Integrity a. Cardiac index (CI) of 2.5 L/min/m2 b. Pulmonary artery diastolic pressure of 26 mm Hg c. Pulmonary artery occlusion pressure (PAOP) of 22 mm Hg d. Systemic vascular resistance (SVR) of 1600 dynes/sec/cm 5

15. The nurse is caring for a patient following insertion of an intraaortic balloon pump (IABP) for cardiogenic shock unresponsive to pharmacotherapy. Which hemodynamic parameter best indicates an appropriate response to therapy?

ANS: A

Desired outcomes for a patient in cardiogenic shock with an IABP include decreased SVR, diminished symptoms of myocardial ischemia (chest pain, ST-segment elevation), increased stroke volume, and increased cardiac output and cardiac index. A cardiac index of 2.5 L/min is within normal limits. All other values are high and would not indicate an appropriate response to therapy.

DIF: Cognitive Level: Understand/Comprehension REF: p. 276

OBJ: Relate assessment findings to the classification and stage of shock.

TOP: Nursing Process Step: Evaluation

MSC: NCLEX Client Needs Category: Physiological Integrity a. The patient is developing neurogenic shock. b. The patient is experiencing an allergic reaction. c. The patient most likely has an elevated temperature. d. The vital signs are normal for this patient.

16. The nurse is caring for an athlete with a possible cervical spine (C5) injury following a diving accident. The nurse assesses a blood pressure of 70/50 mm Hg, heart rate 45 beats/min, and respirations 26 breaths/min. The patient’s skin is warm and flushed. What is the best interpretation of these findings by the nurse?

ANS: A

The most profound feature of neurogenic shock is bradycardia with hypotension from the decreased sympathetic activity. There is no evidence to support an allergic reaction in this scenario. Hypothermia, not an elevated temperature, can develop from uncontrolled heat loss associated with vasodilation in neurogenic shock. Vital signs are not normal given the clinical situation.

NURSINGTB.COM

DIF: Cognitive Level: Analyze/Analysis REF: p. 278

OBJ: Relate assessment findings to the classification and stage of shock.

TOP: Nursing Process Step: Assessment

MSC: NCLEX Client Needs Category: Physiological Integrity a. Administration of atropine sulfate (Atropine) b. Application of 100% oxygen via face mask c. Application of slow rewarming measures d. Infusion of IV phenylephrine (Neo-Synephrine)

17. The nurse is caring for a patient in spinal shock. Vital signs include blood pressure 100/70 mm Hg, heart rate 70 beats/min, respirations 24 breaths/min, oxygen saturation 95% on room air, and an oral temperature of 94.8° F. Which intervention is most important for the nurse to include in the patient’s plan of care?

ANS: C

Hypothermia can develop in neurogenic shock from uncontrolled heat loss; therefore, a patient should be rewarmed slowly to avoid further vasodilation. In shock, a drop in systolic blood pressure to less than 90 mm Hg is considered hypotensive. Atropine is used for symptomatic bradycardia. The patient’s oxygen saturationis 95% on room air with an adequate respiratory rate. The application of 100% oxygen via face mask is not indicated. The patient’s heart rate is adequate to support a normal blood pressure.

DIF: Cognitive Level: Apply/Application

OBJ: Describe management strategies for each type of shock.

TOP: Nursing Process Step: Intervention

MSC: NCLEX Client Needs Category: Physiological Integrity

REF: p. 278 a. Patient response to therapy is appropriate. b. Additional interventions are indicated. c. More time is needed to assess response. d. Values are normal for the patient condition.

18. The nurse has just completed administration of a 500 mL bolus of 0.9% normal saline in a patient with hypovolemic shock. The nurse assesses the patient to be slightly confused, with a mean arterial blood pressure (MAP) of 50 mm Hg, a heart rate of 110 beats/min, urine output of 10 mL for the past hour, and a central venous pressure (CVP/RAP) of 3 mm Hg. What is the best interpretation of these results by the nurse?

ANS: B

Assessed vital signs and hemodynamic values indicate decreased circulating volume. The patient has not responded appropriately to therapy aimed at increasing circulating volume. Additional intervention is needed because response to therapy is not appropriate, values are abnormal, and timely intervention is critical for a patient with low circulating blood volume.

NURSINGTB.COM

DIF: Cognitive Level: Analyze/Analysis

REF: p. 265

OBJ: Relate assessment findings to the classification and stage of shock.

TOP: Nursing Process Step: Assessment

MSC: NCLEX Client Needs Category: Physiological Integrity a. Insertion of an 18-gauge peripheral intravenous line b. Application of cushioned heel protectors c. Implementation of fall precautions d. Implementation of universal precautions

19. The emergency department nurse admits a patient following a motor vehicle collision. Vital signs include blood pressure 70/50 mm Hg, heart rate 140 beats/min, respiratory rate 36 breaths/min, temperature 101° F and oxygen saturation (SpO2)95% on 3 L of oxygen per nasal cannula. Laboratory results include hemoglobin 6.0 g/dL, hematocrit 20%, and potassium 4.0 mEq/L. Based on this assessment, what is most important for the nurse to include in the patient’s plan of care?

ANS: A

Given the patient’s diagnosis, laboratory results, and supporting vital signs, restoring circulating blood volume is a priority and can be accomplished following insertion of an appropriate gauge IV (18) to facilitate blood and fluid administration. Universal precautions, fall precautions, and application of heel protectors are appropriate interventions but are not the immediate priority.

DIF: Cognitive Level: Analyze/Analysis

REF: p. 266

OBJ: Develop an individualized plan of care that includes nursing diagnosis, expected outcomes, nursing interventions, and rationales. TOP: Nursing Process Step: Planning

MSC: NCLEX Client Needs Category: Physiological Integrity

20. The nurse is starting to administer a unit of packed red blood cells (PRBCs) to a patient admitted in hypovolemic shock secondary to hemorrhage. Vital signs include blood pressure 60/40 mm Hg, heart rate 150 beats/min, respirations 42 breaths/min, and temperature 100.6° a. Administer blood transfusion over at least 4 hours. b. Notify the physician of the elevated temperature. c. Titrate rate of blood administration to patient response. d. Notify the physician of the patient’s heart rate.

F. What is the best action by the nurse?

ANS: C

Given the acute nature of the patient’s blood loss, the nurse should titrate the rate of the blood transfusion to an improvement in the patient’s blood pressure. Administering the transfusion over 4 hours can lead to a prolonged state of hypoperfusion and end-organ damage. The heart rate will normalize as circulating blood volume is restored. A mildly elevated temperature does not take priority over restoring circulating blood volume.

DIF: Cognitive Level: Analyze/Analysis

REF: p. 266

OBJ: Develop an individualized plan of care that includes nursing diagnosis, expected outcomes, nursing interventions, and rationales. TOP: Nursing Process Step: Implementation

MSC: NCLEX Client Needs Category: Physiological Integrity

NURSINGTB.COM a. Blood cultures b. Chest x-ray c. Foley insertion d. Serum electrolytes

21. The nurse is caring for a patient in septic shock. The nurse assesses the patient to have a blood pressure of 105/60 mm Hg, heart rate 110 beats/min, respiratory rate 32 breaths/min, oxygen saturation (SpO2) 95% on 45% supplemental oxygen via Venturi mask, and a temperature of 102° F. The physician orders stat administration of an antibiotic. Which additional physician order should the nurse complete first?

ANS: A

Timely identification of the causative organism through blood cultures and the initiation of appropriate antibiotics following obtaining blood cultures improve the survival of patients with sepsis or septic shock. A chest x-ray, Foley insertion, and measurement of serum electrolytes may be included in the plan of care but are not the priority in this scenario.

DIF: Cognitive Level: Apply/Application

REF: p. 283

OBJ: Develop an individualized plan of care that includes nursing diagnosis, expected outcomes, nursing interventions, and rationales.

TOP: Nursing Process Step: Implementation

MSC: NCLEX Client Needs Category: Physiological Integrity a. Frequent turning b. Monitoring intake and output c. Enteral feedings d. Pain management

22. The nurse is caring for a patient admitted to the critical care unit 48 hours ago with a diagnosis of severe sepsis. As part of this patient’s care plan, what intervention is most important for the nurse to discuss with the multidisciplinary care team?

ANS: C

Initiation of enteral feedings within 24 to 48 hours of admission is critical in reducing the risk of infection by assisting in maintaining the integrity of the intestinal mucosa. Monitoring intake and output, frequent turning, and pain management are important aspects of care but are not a critical priority during the first 24 to 48 hours following admission.

DIF: Cognitive Level: Analyze/Analysis

REF: p. 264 |p. 286 Evidence Based Practice Box

OBJ: Develop an individualized plan of care that includes nursing diagnosis, expected outcomes, nursing interventions, and rationales. TOP: Nursing Process Step: Planning

MSC: NCLEX Client Needs Category: Physiological Integrity a. Normal body temperature b. Balanced intake and output c. Adequate pain management d. Urine output of 0.5 mL/kg/hr

23. The nurse is administering both crystalloid and colloid intravenous fluids as part of fluid resuscitation in a patient admitted in severe sepsis. What findings assessed by the nurse indicate an appropriate response to therapy?

ANS: D

Adequate urine output of at least 0.5 mL/kg/hr indicates adequate perfusion to the kidneys following administration of fluid to enhance circulating blood volume. Normal body temperature and adequate pain management are not assessment findings indicating an adequate response to fluid therapy. During fluid resuscitation in severe sepsis, intake and output will not be balanced as circulating fluid volume deficit is restored.

DIF: Cognitive Level: Understand/Comprehension

REF: p. 271 Nursing Care Plan

OBJ: Develop an individualized plan of care that includes nursing diagnosis, expected outcomes, nursing interventions, and rationales. TOP: Nursing Process Step: Assessment

MSC: NCLEX Client Needs Category: Physiological Adaptation a. Administer acetaminophen 650-mg suppository prn every 6 hours for pain. b. Titrate dopamine intravenously for blood pressure less than 90 mm Hg systolic. c. Complete neurological assessment every 4 hours for the next 24 hours. d. Administer furosemide 20 mg IV every 4 hours for a CVP greater than or equal to 20 mm Hg.

24. The nurse is caring for a 70-kg patient in hypovolemic shock. Upon initial assessment, the nurse notes a blood pressure of 90/50 mm Hg, heart rate 125 beats/min, respirations 32 breaths/min, central venous pressure (CVP/RAP) of 3 mm Hg, and urine output of 5 mL during the past hour. Following physician rounds, the nurse reviews the orders and questions which order?

ANS: B

Vasoconstrictive agents should not be administered for hypotension in the presence of circulation fluid volume deficit, which this patient displays. The nurse should question the use of the dopamine infusion. All other listed orders are appropriate and have potential for use in the treatment of a hypovolemic shock.

DIF: Cognitive Level: Analyze/Analysis REF: p. 268 | Table 12-4

OBJ: Develop an individualized plan of care that includes nursing diagnosis, expected outcomes, nursing interventions, and rationales. TOP: Nursing Process Step: Implementation

MSC: NCLEX Client Needs Category: Physiological Integrity a. Blood pressure 100/60 mm Hg b. Swelling at the IV site c. Heart rate of 110 beats/min d. Central venous pressure (CVP) of 8 mm Hg

25. The nurse is administering intravenous norepinephrine at 5 mcg/kg/min via a 20-gauge peripheral intravenous (IV) catheter. Which assessment finding requires immediate action by the nurse?

ANS: B

Swelling at the IV site is indicative of infiltration. Infusion of norepinephrine through an infiltrated IV site can lead to tissue necrosis and requires immediate intervention by the nurse. A blood pressure of 100/60 mm Hg, heart rate of 110 beats/min, and a CVP of 8 mm Hg are adequate and do not require immediate intervention.

DIF: Cognitive Level: Understand/Comprehension REF: Table 12-4

OBJ: Develop an individualized plan of care that includes nursing diagnosis, expected outcomes, nursing interventions, and rationales. TOP: Nursing Process Step: Assessment

MSC: NCLEX Client Needs Category: Physiological Integrity

26. The nurse is caring for a patient in cardiogenic shock experiencing chest pain. Hemodynamic values assessed by the nurse include a cardiac index (CI) of 2.5 L/min/m2, heart rate of 70 beats/min, and a systemic vascular resistance (SVR) of 2200 dynes/sec/cm 5. Upon review of physician orders, which order is most appropriate for the nurse to initiate?

NURSINGTB.COM a. Furosemide 20 mg intravenous (IV) every 4 hours as needed for CVP greater than or equal to 20 mm Hg b. Nitroglycerin infusion titrated at a rate of 5 to 10 mcg/min as needed for chest pain c. Dobutamine infusion at a rate of 2 to 20 mcg/kg/min as needed for CI less than 2 L/min/m2 d. Dopamine infusion at a rate of 5 to 10 mcg/kg/min to maintain a systolic BP of at least 90 mm Hg

ANS: B

The patient is complaining of chest pain and has an elevated systemic vascular resistance (SVR). To reduce afterload, ease the workload of the heart, and dilate the coronary arteries, improving oxygenation to the heart muscle, initiation of a nitroglycerin infusion is most appropriate. Assessment data do not support the initiation of other listed physician order options.

DIF: Cognitive Level: Analyze/Analysis

REF: Table 12-4

OBJ: Develop an individualized plan of care that includes nursing diagnosis, expected outcomes, nursing interventions, and rationales. TOP: Nursing Process Step: Implementation

MSC: NCLEX Client Needs Category: Physiological Integrity a. Documentation of insertion date b. Elevation of the head of the bed c. Assessment for weaning readiness d. Appropriate sedation management

27. The nurse is caring for a mechanically ventilated patient following insertion of a left subclavian central venous catheter (CVC). Which action by the nurse best protects against the development of a central line–associated bloodstream infection (CLABSI)?

ANS: A

Interventions that have been associated with a reduction in CLABSI include timely removal of unnecessary central lines. Documentation of the line insertion date will assist in monitoring this measure. Elevation of the head of the bed, assessment for weaning readiness, and appropriate sedation management are appropriate interventions to reduce the risk of ventilator-acquired pneumonia.

DIF: Cognitive Level: Apply/Application

REF: p. 262

OBJ: Develop an individualized plan of care that includes nursing diagnosis, expected outcomes, nursing interventions, and rationales. TOP: Nursing Process Step: Planning

MSC: NCLEX Client Needs Category: Safe and Effective Care Environment a. pH 7.40, CO2 40, HCO3 24 b. pH 7.45, CO2 45, HCO3 26 c. pH 7.35, CO2 40, HCO3 22 d. pH 7.30, CO2 45, HCO3 18

28. The nurse is caring for a patient admitted with the early stages of septic shock. The nurse assesses the patient to be tachypneic, with a respiratory rate of 32 breaths/min. Arterial blood gas values assessed on admission are pH 7.50, CO2 28 mm Hg, HCO3 26. Which diagnostic study result reviewed by the nurse indicates progression of the shock state?

ANS: D

NURSINGTB.COM

As shock progresses along the continuum, acidosis ensues, caused by metabolic acidosis, hypoxia, and anaerobic metabolism. A pH 7.30, CO2 45 mm Hg, HCO3 18 indicates metabolic acidosis and progression to a late stage of shock. All other listed arterial blood gas values are within normal limits.

DIF: Cognitive Level: Apply/Application REF: p. 284 | Table 12-2

OBJ: Develop an individualized plan of care that includes nursing diagnosis, expected outcomes, nursing interventions, and rationales. TOP: Nursing Process Step: Assessment

MSC: NCLEX Client Needs Category: Physiological Integrity a. Administer pain medication. b. Turn patient every 2 hours. c. Assess core body temperature. d. Apply bilateral heel protectors.

29. The nurse is caring for a patient admitted following a motor vehicle crash. Over the past 2 hours, the patient has received 6 units of packed red blood cells and 4 units of fresh frozen plasma by rapid infusion. To prevent complications, what is the priority nursing intervention?

ANS: C

Hypothermia is anticipated during the rapid infusion of fluids or blood products. Assessment of core body temperature is a priority. While administration of pain management, repositioning the patient every 2 hours, and application of heel protectors should be part of the patient care, given the rapid transfusion of blood products, these interventions are not the priority in this scenario.

DIF: Cognitive Level: Apply/Application

REF: p. 268 | Table 12-4

OBJ: Develop an individualized plan of care that includes nursing diagnosis, expected outcomes, nursing interventions, and rationales. TOP: Nursing Process Step: Assessment

MSC: NCLEX Client Needs Category: Physiological Integrity a. Obtain a stat serum potassium level. b. Order a stat 12-lead electrocardiogram. c. Reduce the rate of dobutamine. d. Assess the patient’s hourly urine output.

30. The nurse is caring for a patient in cardiogenic shock who is being treated with an infusion of dobutamine. The physician’s order calls for the nurse to titrate the infusion to achieve a cardiac index of greater than or equal to 2.5 L/min/m2. The nurse measures a cardiac output, and the calculated cardiac index for the patient is 4.6 L/min/m2. What is the best action by the nurse?

ANS: C

Dobutamine is used to stimulate contractility and heart rate while causing vasodilation in low cardiac output states, improving overall cardiac performance. The patient’s cardiac index is well above normal limits, so the rate of infusion of the medication should be reduced so as not to overstimulate the heart. There is no evidence to support the need for a serum potassium or 12-lead electrocardiogram. Assessment of hourly urine output is important in the care of the patient in cardiogenic shock, but it is not a priority in this scenario.

NURSINGTB.COM

DIF: Cognitive Level: Analyze/Analysis

REF: p. 268 | Table 12-4

OBJ: Develop an individualized plan of care that includes nursing diagnosis, expected outcomes, nursing interventions, and rationales. TOP: Nursing Process Step: Assessment

MSC: NCLEX Client Needs Category: Physiological Integrity a. Administer infusion of 500 mL 0.9% normal saline every 4 hours as needed if the CVP is less than 5 mm Hg. b. Increase supplemental oxygen therapy to maintain SpO2 greater than 94%. c. Administer 40 mg furosemide (Lasix) intravenous as needed if the urine output is less than 30 mL/hr. d. Administer acetaminophen (Tylenol) 650-mg suppository per rectum as needed to treat temperature greater than 101° F.

31. After receiving a handoff report from the night shift, the nurse completes the morning assessment of a patient with severe sepsis. Vital signs are: blood pressure 95/60 mm Hg, heart rate 110 beats/min, respirations 32 breaths/min, oxygen saturation (SpO2)96% on 45% oxygen via Venturi mask, temperature 101.5° F, central venous pressure (CVP/RAP) 2 mm Hg, and urine output of 10 mL for the past hour. The nurse initiates which provider prescription first?

ANS: A

Fluid volume resuscitation is the priority in patients with severe sepsis to maintain circulating blood volume and end-organ perfusion and oxygenation. A 500-mL IV bolus of 0.9% normal saline is appropriate given the patient’s CVP of 2 mm Hg and hourly urine output of 10 mL/hr. There is no evidence to support the need to increase supplemental oxygen. Administration of furosemide (Lasix) in the presence of a fluid volume deficit is contraindicated.

DIF: Cognitive Level: Analyze/Analysis REF: p. 265

OBJ: Develop an individualized plan of care that includes nursing diagnosis, expected outcomes, nursing interventions, and rationales. TOP: Nursing Process Step: Assessment

MSC: NCLEX Client Needs Category: Physiological Integrity a. Blood transfusion with packed red blood cells is required. b. Hemoglobin and hematocrit results indicate hemodilution. c. Fluid resuscitation has resulted in fluid volume overload. d. Fluid resuscitation has resulted in third-spacing of fluid.

32. The nurse is caring for a patient with severe sepsis who was resuscitated with 3000 mL of lactated Ringer’s solution over the past 4 hours. Morning laboratory results show a hemoglobin of 8 g/dL and hematocrit of 28%. What is the best interpretation of these findings by the nurse?

ANS: B

Fluid resuscitation with large volumes of crystalloid results in hemodilution of red blood cells and plasma proteins. Hemoglobin and hematocrit results indicate hemodilution. Given the clinical scenario, there is no evidence to support the need for a blood transfusion and no evidence of fluid overload. Although administration of large volumes of crystalloid can result in hemodilution of plasma proteins leading to third-spacing of fluid, this fact does not support the hemoglobin and hematocrit results.

NURSINGTB.COM

DIF: Cognitive Level: Understand/Comprehension

REF: p. 265

OBJ: Develop an individualized plan of care that includes nursing diagnosis, expected outcomes, nursing interventions, and rationales. TOP: Nursing Process Step: Evaluation

MSC: NCLEX Client Needs Category: Physiological Integrity

Multiple Response

1. Fifteen minutes after beginning a transfusion of O negative blood to a patient in shock, the nurse assesses a drop in the patient’s blood pressure to 60/40 mm Hg, heart rate 135 beats/min, respirations 40 breaths/min, and a temperature of 102° F. The nurse notes the new onset of hematuria in the patient’s Foley catheter. What are the priority nursing actions? (Select all that apply.)

a. Administer acetaminophen.

b. Document the patient’s response.

c. Increase the rate of transfusion.

d. Notify the blood bank.

e. Notify the provider.

f. Stop the transfusion.

ANS: D, E, F

In the event of a reaction, the transfusion is stopped, the patient is assessed, and both the physician and laboratory are notified. All transfusion equipment (bag, tubing, and remaining solutions) and any blood or urine specimens obtained are sent to the laboratory according to hospital policy. The events of the reaction, interventions used, and patient response to treatment are documented although this occurs after immediate action has been taken. Acetaminophen is not warranted in the immediate recognition and treatment of a transfusion reaction. The infusion must be stopped. Increasing the infusion further increases the likelihood of worsening the transfusion reaction.

DIF: Cognitive Level: Analyze/Analysis

OBJ: Describe management strategies for each type of shock.

TOP: Nursing Process Step: Intervention

MSC: NCLEX: Client Needs Category: Physiological Integrity

REF: p. 266 a. Blood pressure b. Heart rate c. Level of consciousness d. Pupil response e. Respirations f. Urine output

2. The nurse is caring for a patient admitted with shock. The nurse understands which assessment findings best assess tissue perfusion in a patient in shock? (Select all that apply.)

ANS: A, C, F

The level of consciousness assesses cerebral perfusion, urine output assesses renal perfusion, and blood pressure is a general indicator of systemic perfusion. Heart rate is not an indicator of perfusion. Pupillary response and respirations do not assess perfusion.

NURSINGTB.COM

DIF: Cognitive Level: Analyze/Analysis

REF: p. 264

OBJ: Relate assessment findings to the classification and stage of shock.

TOP: Nursing Process Step: Assessment

MSC: NCLEX Client Needs Category: Physiological Integrity